Download Simplifying cardiovascular magnetic resonance pulse sequence

Friedrich et al. Journal of Cardiovascular Magnetic Resonance (2014)16:3960
DOI 10.1186/s12968-014-0103-z
EDITORIAL
Open Access
Simplifying cardiovascular magnetic resonance
pulse sequence terminology
Matthias G Friedrich1,23,24*, Chiara Bucciarelli-Ducci2, James A White3, Sven Plein4, James C Moon5, Ana G Almeida6,
Christopher M Kramer7, Stefan Neubauer8, Dudley J Pennell9, Steffen E Petersen10, Raymond Y Kwong11,
Victor A Ferrari12, Jeanette Schulz-Menger13, Hajime Sakuma14, Erik B Schelbert15, ?ric Larose 16, Ingo Eitel17,
Iacopo Carbone18, Andrew J Taylor19, Alistair Young20, Albert de Roos21 and Eike Nagel22
Abstract
We propose a set of simplified terms to describe applied Cardiovascular Magnetic Resonance (CMR) pulse sequence
techniques in clinical reports, scientific articles and societal guidelines or recommendations. Rather than using
various technical details in clinical reports, the description of the technical approach should be based on the
purpose of the pulse sequence. In scientific papers or other technical work, this should be followed by a more
detailed description of the pulse sequence and settings. The use of a unified set of widely understood terms would
facilitate the communication between referring physicians and CMR readers by increasing the clarity of CMR reports
and thus improve overall patient care. Applied in research articles, its use would facilitate non-expert readers?
understanding of the methodology used and its clinical meaning.
Background
CMR is considered the non-invasive gold standard for
many quantitative measurements in cardiovascular disease. It has been repeatedly shown that CMR is a useful
diagnostic tool for a large variety of indications such as
cardiomyopathy, myocarditis, right ventricular disease,
congenital heart disease, myocardial iron assessment,
myocardial ischemia and viability. There are published
standards on CMR indications, data acquisition [1], and
recommendations on how to interpret [2] and to report
[3,4] CMR scans. While frequently used in patient management in tertiary care institutions, CMR is less well
established in community hospitals and private practices.
Many referring physicians have little or no training in this
technique and therefore lack knowledge of CMR principles
and terminology. Several reasons exist for this familiarity
gap, which may cause difficulties in selecting an appropriate testing strategy for a given clinical problem. First,
because of the complex underlying physics, the technological terms often include descriptions of the type, timing,
* Correspondence: [email protected]
1
Philippa and Marvin Carsley Cardiovascular MR Centre at the Montreal Heart
Institute, Universit? de Montreal, Montreal, Canada
23
Departments of Cardiology and Radiology, Montreal Heart Institute/
Universit? de Montr?al, 5000 Rue Belanger, Montr?al, QC H1T 1C8, Canada
Full list of author information is available at the end of the article
repetitiveness and duration of the pulse sequence technique. Hence, publications and, more importantly, clinical
reports often use technical terms that are not intuitively
understood by the referring physician or non-CMR-expert
and do not convey relevant information or contribute to
the quality of the report. Second, these terms often refer to
different aspects of the methodology. ? First-pass perfusion? , for example describes a time period rather than a sequence, whereas ? T2* mapping? relates to the magnetic
relaxation time as a physical parameter of the myocardium.
Third, multiple and sometimes vendor-specific terms are
currently used for the same phenomenon, such as ? delayed
hyperenhancement? and ? late gadolinium enhancement? .
Simplifying CMR pulse sequence terminology could
improve the acceptance and widespread application of
CMR in clinical routine. We therefore propose a simplified terminology for describing CMR techniques when
reporting CMR results in clinical and academic practice,
medical publications, as well as in guidelines or other societal recommendations.
Approach
Given that the primary goal of clinical CMR reports is to
provide a concise description of the clinically relevant
findings, rather than details of technical aspects of the
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Friedrich et al. Journal of Cardiovascular Magnetic Resonance (2014)16:3960
study, we suggest simplifying CMR sequence terminology. MR-specific technical terms such as generic sequence names should be available as a technical glossary
upon request.
Clinical research papers should present such information as part of the methods section, but not in abstracts.
Publications on MR technology are not subject to these
recommendations.
We are aware that a simplification of the terminology
comes at the cost of accuracy with respect to details of
the applied protocols. While exact knowledge of the
sequence details may be occasionally relevant for followup scans, such detailed information however is not contained in the sequence name anyway. Instead, the overall
impact of using less complex terms on the application
and its benefit to patients outweigh theoretical disadvantages and that the use of arcane, technical language in
clinical reports may rather lead to a disconnect between
imagers and referring clinicians than to improved trust.
Proposed terminology in clinical CMR reports
Delivering useful information to referring physicians is
the primary objective of clinical reports. The question put
forward to the imager should be answered as completely
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and as specifically as possible, and important additional
findings should be reported.
We propose to primarily use terms that incorporate
the term CMR, the information on whether the methodology was used for mere visualization or also included
quantitative assessment and, wherever possible, the diagnostic target of the pulse sequence.
While previously published recommendations of the
Society for Cardiovascular MR (SCMR) list sequence
names [3], other societal recommendations on reporting
of CMR images do not specifically include listing technical terms [1] or even recommend the use of more generic terms [4,5]. Of note, the use of the detailed pulse
sequence description may be helpful for follow-up scans
and thus should be included where appropriate, at the
discretion of the reporting physician in the technical
section of the report. In the more narrative section of a
report however, non-generic technical language should
be avoided. The term ? Late gadolinium enhancement
(LGE) CMR? represents an exception. Since this approach
is not specific for a certain tissue pathology but may in
fact reflect necrosis, fibrosis, infiltration or other causes
for an increased volume of distribution of gadolinium, the
term LGE can be used as such, followed by its diagnostic
target in this particular scan. Table 1 lists currently used
Table 1 Proposed simplified CMR sequence terminology
Used terms (examples)
Term suggestions
for clinical reports
Modifiers for scientific/
technical publications
Black-blood T1-weighted (half-Fourier, single-shot, fast spin echo, doubleinversion recovery) dark blood spin echo sequence with or without contrast
agent; with or without fat saturation, proton-density weighted spin echo
sequence
Black-blood CMR
?
2D/3D inversion-recovery gradient echo sequence
Late gadolinium
enhancement (LGE) CMR
Regular/single-shot 2D/3D phase-sensitive SSFP
Delayed (hyper) enhancement sequence
T2-weighted single-shot/fast spin echo double-inversion recovery/triple-inversion
recovery dark/black blood spin echo sequence/T2-prepared SSFP with/without fat
saturation
Edema CMR
Balanced steady-state- free-precession gradient echo sequence, spoiled gradient
echo cine sequence with/without contrast agent
Cine CMR
Gradient echo cine sequence with spatial modulation of magnetization (SPAMM)
Strain CMR
Steady-state- free-precession or spoiled gradient echo sequence with tissue
motion analysis (e.g. feature tracking)
T1-weighted saturation recovery gradient echo sequence with echo-planar, SSFP,
or hybrid read-out
Perfusion CMR
In plane/through-plane motion-encoded phase-sensitive spoiled gradient echo
sequence
Flow CMR
4D phase contrast velocity sequence
T2*-weighted spoiled gradient echo sequence
Iron CMR
T2* mapping sequence
Time-Of-Flight MR coronary angiography sequence with/without contrast SSFP
MR coronary angiography sequence
CMR Coronary Angiography
*: ? Details? indicates any specific methodology used for data acquisition, post-processing and evaluation.
using [sequence name,
details*] (applies to all
examples)
Friedrich et al. Journal of Cardiovascular Magnetic Resonance (2014)16:3960
terms for frequently implemented sequences and the proposed simplified terminology to present them. This list applies to all MR systems, regardless of the field strength or
other technical variations. If new sequences are developed
for new purposes, a new, similarly clear term should be
identified and used.
The conclusion of the clinical report should translate
the findings described in the body of the report into clinically meaningful information and, if possible, propose a
diagnosis that appears most consistent with the findings.
Thus, descriptors of the technique are not required at all.
Proposed terminology in scientific reports and
publications
When describing CMR pulse sequences in experimental,
preclinical or clinical reports submitted to journals and
other media, a detailed and accurate description of hardware and sequences is essential. Therefore, a simplification
of the descriptive terms should be avoided. Yet, a detailed
technical description can be preceded by terms which can
be understood by readers outside the field of CMR. Thus,
we propose to use the more commonly understood terms
(such as flow CMR) followed by the detailed sequence
name.
A list of terms should be part of societal (e.g. Society for
Cardiovascular Magnetic Resonance (SCMR)) recommendations, based on a careful evaluation of the existing body
of evidence, and distributed to journals and media. The
set of recommendations should respond to applications
from the SCMR community with periodic updates of the
recommended term list.
We strongly encourage clinical CMR readers, scientists,
MR equipment and software vendors to consider these
recommendations as a service to the community and their
patients.
Summary
We propose the use of more commonly understood terms
for the description of CMR protocols in clinical CMR reports that should include the purpose of the sequence and
the modality (CMR). In technical or scientific publications, this should be followed by the detailed name of the
pulse sequence and any specific approach used for postprocessing and evaluation.
Competing interests
The authors declare that they have no competing interests.
Authors? contributions
MF proposed a first data, all authors have drafted the manuscript together.
Author details
1
Philippa and Marvin Carsley Cardiovascular MR Centre at the Montreal Heart
Institute, Universit? de Montreal, Montreal, Canada. 2Bristol Heart Institute,
University of Bristol, Bristol, UK. 3Stephenson CMR Centre at the Libin
Cardiovascular Institute of Alberta, Calgary, Canada. 4University of Leeds,
Leeds, UK. 5The Heart Hospital, London, UK. 6Hospital Santa Maria, Lisbon
Page 3 of 3
University, Lisbon, Portugal. 7Cardiovascular Imaging Center, University of
Virginia Health System, Charlottesville, VA, USA. 8Centre for Clinical MR
Research, John Radcliffe Hospital, University of Oxford, Oxford, UK. 9Royal
Brompton Hospital, National Heart and Lung Institute, Imperial College,
London, UK. 10NIHR Cardiovascular BRU at Barts, William Harvey Research
Institute, Queen Mary University of London, London, UK. 11Brigham and
Women? s Hospital, Harvard Medical School, Boston, MA, USA. 12University of
Pennsylvania Medical Center, Philadelphia, PA, USA. 13Charit?
Universit?tsmedizin Berlin and HELIOS-Klinikum, Berlin, Buch, Germany. 14Mie
University Hospital, Mie, Japan. 15UPMC Heart & Vascular Institute, University
of Pittsburgh, PA, USA. 16Institut Universitaire de Cardiologie et de
17
Pneumologie de Qu?bec, Universit? Laval, Qu?bec City, QC, Canada.
Klinik
f?r Innere Medizin/Kardiologie, Herzzentrum/Universit?t Leipzig, Leipzig,
Germany. 18Universit? ? La Sapienza? , Roma, Italy. 19Alfred Hospital and Baker
Heart and Diabetes Institute, Melbourne, Australia. 20Auckland University,
Auckland, New Zealand. 21Department of Radiology, Leiden University
Medical Center, Leiden, The Netherlands. 22King? s College, London, UK.
23
Departments of Cardiology and Radiology, Montreal Heart Institute/
Universit? de Montr?al, 5000 Rue Belanger, Montr?al, QC H1T 1C8, Canada.
24
Departments of Cardiac Sciences and Radiology, Montreal Heart Institute,
University of Calgary, 5000 Rue Belanger, Montr?al, QC H1T 1C8, Canada.
Received: 13 June 2014 Accepted: 27 November 2014
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